Public policy on community involvement since 1997 has provided UK health services with a clear mandate for change and opportunities for innovation. The challenge of moving community involvement beyond the level of rhetoric to mainstream practice is explored in a series of published works provided to support this submission. The focus is on engagement mechanisms at the public interface between services and communities. It is argued that this area, whilst being under-researched, is critical to understanding the acknowledged implementation gap. The published works examine change mechanisms with the potential to initiate and support better connections between organisations and lay people. A further theme concerns the generation of evidence on community involvement. Arguments reflect the progression from initial research questions embedded within commissioned research to critical analysis of models. The accompanying synthesis appraises evidence emerging from an evaluation of a health action zone team. This is followed by critical discussion of a series of evaluations of innovative programmes, including the Patient Advice and Liaison Service, health trainers and arts for health. The central argument is that differences in operational models do not explain shifts in organisational practice, instead connecting themes illuminate the importance of organisations adopting an external orientation and being able to foster networks. The utility of social entrepreneurship is examined, as is the value of roles bridging organisational boundaries. The evidence presented is underpinned by a robust discussion of the role of evaluation for learning and the adoption of appropriate methodologies. The significance of an evaluation framework for the measurement of community involvement is highlighted. Overall it is argued that the body of work presented has made a unique contribution to the development of professional and research practice locally and nationally, and has also furthered understandings of mechanisms to bridge the implementation gap and measure progress

The British Government, since 1997, have placed a strong emphasis on public health and the reduction of health inequalities. Alongside this, they have progressed a major reform of the NHS which aims to 'shift the balance of power' to the frontline. Primary care is an increasingly important aspect of the Government's new agenda, which aims to improve health for everyone, and for the worst off in particular. This thesis identifies general practice, and the core practitioners that work within it, as key potential contributors to a public health agenda. But 'public health' is a conceptually contested terrain, and as a concept, can be understood and interpreted in a myriad of ways. The impact of this lack of shared understanding is explored both for policy making and implementation, and for the development of public health practice in primary care. This research brings together public health and primary care literatures in order to illuminate the historical and organisational contexts within which current developments are taking place. It critically analyses the public health discourse of New Labour policy documents in order to explore the ways in which 'public health' is understood and talked about within recent government policy, and the government's expectations of primary care practitioners, in terms of their public health roles. Finally, the research draws on case study material from one (pre-2002) health authority area in England to examine practitioners' understandings of public health, and their perceptions of their public health roles. Using Wenger's (1998a) social theory of learning as a framework, it looks at the organisational and wider contexts in which practitioners work, and explores how varied and unclear understandings of public health, both in policy and practice, might be affecting practitioners' engagement with public health. The study highlights the dangers of vagueness surrounding the term public health, and finds a tendency both in policy and practice to regard it as a set of activities, rather than as an approach to work. Its malleability means that it can be interpreted both in a politically acceptable way, and in a way that fits within existing practice. Thus, as a concept, it loses its radical edge and is no longer something that challenges or guides policy and practice. The research finds that the ways in which practitioners interpret public health can contribute to their non-engagement in the public health agenda. This is not helped by conflicts within policy which threaten the development of stronger public health roles within general practices. The thesis concludes by recommending the development of shared understandings of public health, particularly as a valuedriven approach to work, rather than as a set of activities.

No description available.

The realisation of the importance of user involvement in the delivery and provision of health services is shared across the range of interested parties. The World Health Organisation (WHO), UK Department of Health (DOH) and English National Health Service (ENHS), health care professionals, and voluntary organisations, all actively subscribe to the transformation of healthcare service provision from a managed service to a collaborative service.

This thesis explores the complex nature of the policy process through the actions and intentions of the multiplicity of national and local actors involved in the development, through implementation, of a particular initiative: direct payments for community care. The methodology combines both 'top down' and 'bottom up' perspectives on policy- action (Sabatier, 1986) in a case study, using documents, personal accounts and observations. The case study follows New Labour's efforts to secure policy effectiveness while delegating the responsibility for implementation to local councils. The research focused primarily on one authority. It took place within the context of that authority's efforts to 'modernise' community care through pragmatism, partnership, participation and centralised performance management. The findings are compared to experiences in another authority, thereby combining the validity of Pawson and Tilley's (1997) assertion that the outcomes of the ideas and opportunities offered by policy initiatives vary with context. This comparison illustrates the influence of contextual features on policy outcomes: local politics, history, culture and the community's expectations and experiences of policy developments. In the 'policy-action' relationship examined, ultimate objectives and the means of achieving them were re-defined and prioritised through negotiation and experience, as parts of New Labour's own discourse were appropriated (Newman, 2001). The relevance of Lindblom's (1959) classic 'muddling through' account of the process is thus revealed, along with the contribution of' street level bureaucrats' in interaction with citizens (Lipsky, 1980), to policy development through implementation. The influences of values and convictions, as well as personal experience and interests, on the agency of policy actors are highlighted. The thesis concludes that central government will only achieve the objective of 'promoting independence', through initiatives intended to extend choice and control to most service users, when and where it engages and empowers people at the level of citizen-practitioner interaction.

Background: The last few decades have seen a growing emphasis on evidence-based decision making in health care. Systematic reviews synthesising and evaluating research have been a key component of this movement. However, there is concern that such syntheses do not have the expected impact on policy and practice and more work is needed to enable us to maximise their potential. The aim of this study was to increase understanding of the likely impacts of systematic reviews on policy and identify factors that might facilitate their influence. Methods: My own previously published work is integral to this study. I took ten systematic reviews on which I am an author and used established methods for the evaluation of research impact, including, bibliometrics and documentary review, to examine whether these reviews had influenced policy development. Data from these analyses were combined with an overview of the literature to identify factors that might increase impact. Results: The reviews had influenced the development of national and international policy, although much of the impact was at a ‘micro’ level in the form of practice guidelines. There was considerable variation in the impact of the reviews. Reviews evaluating fluid resuscitation and road safety interventions showed the greatest evidence of impact and a review of qualitative studies on barriers to fall prevention the least. Differences might be explained by time since publication, type of question, importance to policy makers, the nature and strength of the evidence, the purpose of the review and the networks and strategies used for dissemination. Conclusions: Systematic reviewers should consider the desired impacts of their work and include appropriate strategies for increasing impact, these should be detailed in the review protocol. This might include specifying methods to address applicability to particular contexts, and devising active strategies for dissemination.

A democratic deficit is often assumed where the local community has little direct influence on local policy decisions and where change is unresponsive to the community's needs (Murat and Morad, 2008). The UK government embodied patient and public involvement (PPI) in a wide range of activities and a variety of purposes. Patient involvement and public involvement are distinct and are achieved in different ways. However, the conflation of these distinct terms arid the confusion about the purpose of involvement has led to muddled initiatives in the UK and uncertainty about what should be done to achieve effective PPI (Cowden et al., 2007). Nevertheless, patient and public involvement had the potential to play a key role in NHS services by bringing about service improvement and improving public confidence via engaging democratic procedures (Le Grarid, 2007). In Greece, the health care system is highly centralised and removed from welfare principles such as equity, responsiveness and efficiency. Virtually every aspect relating to health care financing and provision is subject to control by the ministry of health (Karassavidou and Glaveli, 2007). The state never got involved in ongoing design of the health sector at a local level instead its role was one of exercising strong regulatory control over insurance funds and public hospitals (Karrasavidou and Glaveli, 2007). Additionally, the existence of out of pocket expenditure within the NHS, which mainly consisted of informal payments for care, was developed as a complement to public funding (Mossialos and Davaki, 2002). Hence, several reform plans during the 1980s concerning fair provision of services failed owing to an array of the aforementioned interrelated economic, political and social factors that channel potential changes towards failing to employ democratic procedures and transparency (Davaki and Mossialos, 2005). These conditions create unfavorable conditions for the introduction of mechanisms such as PPI. The aim of this study is to explore the effectiveness of patient and public involvement mechanisms, employed in the UK and Greece, in respect of reducing 2 a perceived democratic deficit within the respective NHS structures. The main objectives of this study are to investigate the meanings that different stakeholders give to PPI in the UK and -Greece, to explore stakeholders' opinions of effective ways of involveme~t, to identify motivations in getting involved; and to compare and contrast effectiveness of involvement mechanisms in both countries. This study employed qualitative research methods. Focus group discussions were the main data collection method. Initially 11 focus group discussions in total were conducted and analysed, two in the UK and nine in Greece with a total of 92 participants involved. The empirical findings of this research have added to our understanding about patient and public involvement as a mechanism of strengthening democratic values within the NHS and of making health care service more responsive to patients' needs. This study found that patients and members of the public perceive that there is a 'democratic deficit' within the NHS due to the dominance of the health professionals in decision making and the patients' and the citizens' limited power in changing health care policy. Current involvement mechanisms . in the UK were not considered to be powerful enough to affect policy at a local or at a national level. In contrast to England, in Greece there appears to be no formal patient and public involvement structures in place, nor was there any real appetite to create formal structures. This was as a consequence of a number of factors including the centralised nature of state public services provision, the perceived corrupt and unequal power relationships between various sections of society, the power of the medical profession and its expert knowledge and citizens lack of enthusiasm for involvement unless the issues were personally relevant.

No description available.

This thesis challenges conventional approaches to policy analysis associated with a rational model of decision-making and shows how a discursive approach can add essential insights to contemporary policy debates. I investigate primary care research policymaking as a socially accepted set of practices, asking: what are the historical, social and ideological origins of primary care research in England? Which discourses have dominated the debate, and why? What are the tensions between discourses relating to primary care research policy and any potential means for coping with these? I draw on the theoretical and methodological approach of discourse analysis and use Parker's (1992, 2002) framework for distinguishing discourses to inform the selection and analysis of 29 policy documents (from 1971 to 2005) and 16 historical and contemporary policy stakeholders for in-depth interview. Identification of discourses is aided through importing relevant theory applying focused questions exploring the use of rhetorical devices incorporating contextual information to appreciate how and why discourses are shaped and comparing and contrasting policy language. This is brought together into a descriptive and theoretically situated account through the methodological process of writing. Findings show how primary care research policies have shaped and been shaped by prevailing discourses. Political emphasis on a primary care-led NHS in the 1990's led to increased political recognition and favourable changes in the research budget. However, the Utopian era that followed fell into decline as primary care research no longer aligned with scientific, economic and global discourses emphasising microscopic 'discovery' exploitation of information large-scale consumption and the contribution of highly technological activities to 'UK pic'. Unable to compete on these terms, primary care research has been repositioned as a strategic resource and population laboratory for epidemiological research. In addition to illuminating the emergent nature of policymaking, this work provides a useful framework for analysis of national policy.

This thesis explores the co-ordination of public services through an examination of the way organisations in the English NHS negotiate incentives for competition and co-operation to deliver co-ordinated care to diabetic patients. Whilst the bodies responsible for the planning and provision of local services in the English NHS need to co-operate to ensure the co-ordination of services across organisational boundaries, they are also subject to a wide range of system reform mechanisms which encourage competition between the providers of services. The tension between these incentives raises questions about how organisations and professionals understand their objectives in this environment, and how this understanding translates into the relationships between organisations as they work together to plan and provide co-ordinated services. Both the wider institutional context affecting competition and co-operation in the NHS, and commissioner and provider behaviour in the local context are examined. This examination is conducted in the light of the hierarchy, market and network modes of co-ordination. The research examines the applicability of the theories of ‘co-opetition’ and Ostrom’s Institutional Analysis and Development framework as analytic frameworks to help understand the behaviour of NHS organisations and professionals as they work together to provide co-ordinated services. Theories of behaviour from game theory, economics, economic sociology and organisational studies are also explored to identify the rules of behaviour which organisations and professionals follow. The review of the decisions of national regulatory bodies suggested that the promotion of competition was secondary to other concerns, although this position appeared to be changing following the implementation of the Health and Social Care Act 2012. Whilst co-opetition and Ostrom’s IAD framework are concerned with how incentives for competition and co-operation can co-exist and can be managed for the benefit of all, at a local level the impact of incentives for both competition and co-operation on the behaviour of organisations and professionals was blunted by the predominance of hierarchical modes of co-ordination. Local context was found to be important in shaping the deployment of incentives for competition and co-operation, and establishing the rules of behaviour. Where organisations and professionals were exposed to incentives for both competition and co-operation, the delivery of services did not appear to be unduly affected, but lack of trust inhibited the sharing of sensitive information between parties, and reduced the quality of interactions in relation to other activities. It is suggested that the development of network relationships within the NHS hierarchy should be encouraged in order to realise the benefits which can be gained from close co-operative working relationships between organisations.